Deleading notification - Unit 3 RECEIVED
Department of Public Health-Childhood Lead Poisoning Prevention Pro5gLl 12018
Deleading Notification CITY OF SALEM
BOARD OF HEALTH
Please complete all sections of this form clearly. Incomplete or illegible forms will be returned
Lead Paint Inspector Aovv ac 1 License"�-- - Inspection Dater
Propern. Owner
Propern Ov;ner's Address ` , _ Zip Code _
r
Authorized person performing work: Sainnang Sar Lic=Auth.= IX 500074
Address of authorized person_ 71 0A Summer St. Lynn, Ma. Zip Code 01905
Telephone Number(710 596-8735
Address where the work will be done.
Building Name(if any) Floor
StreetAddress, A -
Cin Zip Coded � The propem is a�u1ti-family single fami Iv.
Deleading Method(s):
ib Making paint intact(high risk) 4laking pairn intact(moderate � Applying vinyl siding on exterior
j Demolition risk) :3 Component removal(Iov- risk
It Scraping r j Liquid encapsulant components)
M Component.remov-al replacement Covering z Other:_
a Dipping I Capping baseboards
�%\c�
The work will begin on, [Wnd will finish b.� �a The work be done in the 8 am 5 pm orYesv.eekends.
In Case of Emergenev Contact` Samnang Sar
Daytime Phone-r f 781 ) 596-8735 . Evening Phone__ Same
The Property Owner must complete and sign the following information:
I certifiv that only authorized persons who have complied with the training requirements of the Massachusetts Lead Poisoning
Prevention and Control Regulations. 105 CMR 460.000. will conduct deleading work. I further certiA-that the authorized
person(s) will not exceed the scope of his her authority and will be performing onh,those activities indicated above. All of the
information contained in this document is true and correct to the best of my knowledge and belief.
Signed - -— -
The following peoplelagencies must be notified ten days be nning work:
i. Occupants of the dwelling unit
2. All other occupants of the residential premises. ifan%work will be done in the common areas
3. Childhood Lead Poisoning Prevention Program. DPH Fax 081)774-6700
MWRHO
5 Randolph St. Donovan Building
Canton. MA 020?1
-I. asbestos and Lead Program. DLNN'D
19 Staniford Street. 1' Floor. Boston. MA 0_114 Fax(617)626-6965
4;. Local Board of Health Code Enforcement A-enc%
If the home is on the State Re_isterof Historic Place,wall the NlA Historical Commission at(617) 727-8470